Antimicrobial resistance (AMR) has emerged as an urgent global public health threat, imposing a substantial burden in Nepal. Since the groundbreaking discovery of penicillin in 1940, antimicrobials, particularly antibiotics, have been pivotal in saving millions of lives. However, irrational use of antimicrobials-medicines used to treat bacteria, viral, parasitic, and fungal infections of humans, animals and plants-contributed to emerge AMR. This phenomenon renders once-effective treatments impotent against a broad spectrum of microorganisms, complicating the treatment of infections and exacerbating the financial strain on patients and governmental healthcare systems. Recognizing
AMR as a top-ten global public health concern and a silent pandemic, the World Health Organization emphasizes the urgency of action and multi-sectorial engagement through a One Health approach.
In 2019, bacterial AMR attributed to a staggering 1.27 million deaths globally, with an additional 4.95 million deaths associated. Notably, pathogens like methicillin-resistant Staphylococcus aureus played a significant role in this alarming toll. Low- and middle-income countries, including Nepal, bear a disproportionate burden of AMR, posing serious challenges to healthcare systems and sustainable development goals.
Recognizing the gravity of the situation, Nepal proactively initiated to address AMR by signing the Jaipur Declaration in 2011. However, like other nations, Nepal grapples with significant challenges in swiftly addressing with this escalating AMR crisis. Scientific studies reveal alarming levels of irrational antimicrobial use in humans, animals, and food production. Industrial broiler poultry farms and animal farming exhibit high prevalence rates of antimicrobial use, accompanied by antibiotic residues and multidrug-resistant bacteria. Clinical studies underscore resistance to widely used first and second lines of antibiotics, necessitating the use of last-resort antimicrobials to combat severe bacterial diseases. Improper and uncontrolled antimicrobial use poses a severe threat, fostering the emergence of deadly multi-drug-resistant bacteria. Research in Kathmandu's slums unveils an invisible public health threat, with identified antimicrobial-resistant genes of global health importance at the human-animal-environment interface.
The absence of nationwide authentic data on AMR's public health and economic impact in Nepal underscores the need for evidence-based data generation and containment strategies. The country drafted the 'National AMR Containment Action Plan 2016' and is presently endorsing the 'National Action Plan on AMR (NAP-AMR) 2023–2028.' Aligned with a One Health approach involving multisectoral engagement, the NAP-AMR 2023-2028 aims to address key contributors to AMR in Nepal. These include overuse and misuse in the One Health interface-the human health sector, non-therapeutic or growth promoter antimicrobial use in animals, and limited awareness of good manufacturing practices (GMP) in animal husbandry and agriculture.
Despite these initiatives, challenges persist, including incomplete and inconsistent AMR surveillance data in animal and agriculture sectors, lax enforcement of laws and regulations, and limited public awareness. A multipronged approach, encompassing coordinated education and awareness, enhanced One Health surveillance, evidence-based information generation, infection prevention control, rational use in the One Health interface, and research and innovation, is imperative. Emphasizing inclusive multistakeholder engagement and periodic evaluation of AMR actions are vital to ensure sustained commitment from all sectors.
The existing knowledge gap on AMR among diverse stakeholders, including the general population, farmers, journalists, pharmacists, healthcare professionals, local government authorities, and policymakers, poses a significant obstacle. Bridging this gap requires coordinated capacity-building tools, tailored workshops, and focused training efforts. Inclusive awareness campaigns with gender equity and empowering community-level media coverage are vital components of effective AMR communication for containment.
Continued efforts are necessary to enhance media engagement, driving behavioral change through media influence. The media can act as a catalyst for responsible antimicrobial use, disseminating evidence-based information to the public, healthcare providers, and policymakers. By cultivating an informed and proactive media landscape, significant contributions can be made to global AMR mitigation.
The National Drug Policy 1995 requires amendment to ensure the quality, proper manufacture, sales and distribution, use, and waste-management of antimicrobials based on the standard protocol. Effective regulation of substandard and falsified antimicrobials and illegal transportation of unregistered drugs from open borders is urgent.
As the World Antimicrobial Resistance Awareness Week 2023 is celebrated on November 18-24 with the theme "Preventing Antimicrobial Resistance Together," a collaborative approach involving all stakeholders is crucial.
The escalating AMR demands urgent, multipronged interventions. The country's commitment to AMR containment is evident through policy initiatives, but the implementation of these measures requires multisectoral partnership, regulatory pharmaceutical system strengthening, enhanced AMR surveillance in the human, animal, and agriculture interface, and sustained evidence-based education/public awareness and political commitment. Addressing the key contributors and challenges is crucial for Nepal to contribute significantly to the global fight against AMR and safeguard the health of the general population.
To mitigate this crisis, the National Antibiotic Treatment Guidelines 2023 for Human and Animal Health must be swiftly approved and implemented. The National Health Policy 2019 defines antimicrobial resistance as a public health challenge, necessitating the formal approval and implementation of the NAP-AMR 2023-2028 for effective prevention and control. Evidence-based education, awareness, understanding, and training can improve prudent use and behavioral practice change.
Effective measures to prevent and control infection include improving policies, guidelines, and programs, ensuring proper management of hazardous waste, and early diagnosis and management of emerging infectious diseases.
The One Health approach encourages prudent antimicrobial use in human, animal, agricultural, and environmental sectors. Alternative therapy- Ayurveda related research and innovation, a multipronged approach, and initiatives on multisectoral engagement, international cooperation, and investment are essential.
Urgent calls aimed at 'Over-the-Counter' antimicrobial dispensing without prescription should be banned. Antimicrobial use in the human-livestock-agriculture-environment must abide by standard guidelines, rules and regulations. Improper antimicrobial prescription without diagnostic evidence for personal benefit, disobeying ethical grounds, should be monitored and punished. Awareness campaigns to stop antimicrobial self-medication need to be enhanced for public behavioral changes in its rational use. Effective implementation of these actions in the present context could be a 'Brahmastra' to contain AMR in Nepal. As our responsibility to preserve antimicrobials for the new generation to save their lives is also an urgent call.
Dulal is a Senior Technical Advisor - AMR at USAID Medicines, Technologies and Pharmaceutical Services (MTaPS) Program Nepal
